The CDC says that Lyme disease is most common among boys aged 5-19. This age group is affected at three times the average rate of all other age groups. Around 25% of all reported cases are children.

Children with Lyme disease have special issues. Since they did not have much of a history of wellness prior to becoming ill, Tthey don’t know what “normal” is. They can’t always explain what is feels wrong. Because the symptoms of Lyme disease can be non-specific, vague, and changeable, parents and teachers may suspect them of malingering or making things up to gain attention. It is also difficult for parents to discern when their child’s symptoms are worse or better, given the difficulties children have making that determination themselves.

Children with Lyme disease may miss important developmental stages, due to because of social isolation caused by chronic ill health, and the failure of their peers to understand the nature and degree of their illness. They may fall behind their peers in school because their brains are not functioning properly. Children suffer when their bodies hurt, when the illness causes them not to be able to have restorative sleep every night, when they must struggle in school, when they don’t even feel like playing. They may feel confused, lost, and betrayed by caregivers who fail to recognize that something organic is going on, but instead blame them.. Isolation from parents occurs when parents don’t understood the nature of the illness, and the implications for the child’s functioning.

According to research, children are bitten by ticks more frequently around the head and neck, making them more vulnerable to brain and central nervous system infections. The resulting neurologic symptoms of Lyme disease are often misdiagnosed. Lyme pediatric specialist Charles Ray Jones, MD, compiled a list of common symptoms of infection in his young patients:

Among Jones’ patients, 50% have no known history of deer tick attachments and fewer than 10% have a history of an erythema migrans Lyme rash (bull’s-eye).

According to neuropsychiatrist Brian Fallon, MD, director of theSurveys University Lyme Disease Research Center and principal investigator of an NIH-funded study on chronic Lyme disease, about 15 percent of infected patients (not necessarily of children) develop objective neurologic abnormalities, most commonly displaying part of the triad of aseptic meningitis, cranial neuritis, and motor sensory radiculitis.

Case reports (again, not necessarily of children) have linked a variety of neurologic syndromes to late Lyme disease, including:

Karen Hassan sat beside her bedridden son, unsure of what was happening. Daniel, 15 at the time, was suffering from seizures and extreme fatigue, often unable to move. She thought he was going to die, she said, and spent every night beside him so he wouldn't be alone.

After a decade of confusion, Daniel Hassan of Brookhaven, now 23, was diagnosed last year with Lyme disease.

He, along with six others fighting the disease, read an account of his experience yesterday before those attending a "Children of Lyme" town-hall-style meeting at the Manorville Fire Department.

The meeting was a platform to raise awareness about Lyme disease and discuss the struggle against it. The best treatment for Lyme is a matter of debate, with some advocating long-term medicating of patients and others saying that can be harmful.

Eva Haughie, president of the Empire State Lyme Disease Association, the sponsor of yesterday's meeting, said her group and others, including the International Lyme and Associated Disease Society, believe long-term medication is needed. They cite patients whose symptoms recurred for up to 10 months after treatment began.

On the other side of the debate, the Infectious Disease Society of America and some physicians say Lyme disease can be cured in 28 days with antibiotics. Longer treatment, the society says, could cause serious illness or allow patients to develop a tolerance for the antibiotic, rendering it ineffective for future use.

Lyme disease is a potentially life-threatening, tick-borne infection. According to the national Centers for Disease Control and Prevention, in 2005 there were more than 233,000 cases reported nationwide, 55,650 of which were New York residents. The disease most often affects children ages 5-14, according to the CDC report.

Commonly associated with causing cognitive dysfunction, fatigue, memory loss and stunted development, Lyme disease also can result in heart disease and depression, said Diane Blanchard, co-president of Time for Lyme Inc., a nonprofit organization based in Greenwich, Conn., which endorses long-term medication for patients.

Blanchard cited an October 2005 study by Johns Hopkins University Medical Center that showed current Lyme tests miss 75 percent of cases, saying more sophisticated diagnostic regimens are needed.

Since he was 12, Daniel Hassan told the group, he has been hospitalized five times in three Long Island hospitals. In August 2006, he underwent a spinal tap, when a doctor confirmed he had Lyme.

Listening in the audience was Jane Mills, 44, of West Hartford, Conn. Her son Stephen, 9, was bitten by a deer tick when he was five and diagnosed with Lyme disease. Subsequently, his knees swelled from babesiosis and bartonella, two infections that frequently accompany Lyme, and he spent his first-grade year in a wheelchair.

"He missed 37 days of school last year," his mother said. "One year he's at the top of his class, the next he needs to be placed in a special learning program."

"Borrelia-associated early-onset morphea": A particular type of scleroderma inchildhood and adolescence with high titer antinuclear antibodies? Results of acohort analysis and presentation of three cases.

BACKGROUND: Morphea is an inflammatory autoimmune skin sclerosis of unknownetiology. A causative role of Borrelia burgdorferi infection has beencontroversially discussed, but no conclusive solution has yet been achieved. OBJECTIVE: Intrigued by 3 young patients with severe Borrelia-associated morpheaand high-titer antinuclear antibodies, we retrospectively examined therelationship between Borrelia exposure, serologic autoimmune phenomena and ageat disease onset in morphea patients. METHODS: In 90 morphea patients thepresence of Borrelia-specific serum antibodies was correlated to the age atdisease onset and the presence and titers of antinuclear antibodies. Patientswith active Borrelia infection or high-titer antinuclear antibodies due tosystemic sclerosis or lupus erythematosus served as controls. RESULTS: We observed a statistically highly significant association between morphea, serologic evidence of Borrelia infection, and high-titer antinuclear antibodies when disease onset was in childhood or adolescence. LIMITATIONS: Because pathogenic Borrelia species may vary in different geographic regions the relevance of Borrelia infection in morphea induction may show regional variations. CONCLUSION: B burgdorferi infection may be relevant for theinduction of a distinct autoimmune type of scleroderma; it may be called"Borrelia-associated early onset morphea" and is characterized by thecombination of disease onset at younger age, infection with B burgdorferi, andevident autoimmune phenomena as reflected by high-titer antinuclear antibodies.As exemplified by the case reports, it may take a particularly severe course andrequire treatment of both infection and skin inflammation. PMID: 19022534 [PubMed - as supplied by publisher]

OBJECTIVE: To measure cognitive effects of Lyme disease (LD) in a pediatric population 4 years after disease onset. METHODS: Prospective, blinded, multivariable controlled study of cognitive skills in children who have been treated for LD. The setting was a children's hospital in an area endemic for LD. Twenty-five children with strictly defined LD were compared with 17 control children (6 disease-control and 11 sibling-control). Outcome measures: An extensive set of neuropsychological measures was administered. These included assessment of the cognitive areas of IQ, information processing speed, fine-motor dexterity, novel problem solving and executive functioning, short term and intermediate memory, and acquisition of new learning. Parents' ratings were also obtained concerning disease impact upon everyday activities.

RESULTS: Seventeen of the 18 neuropsychological test measures showed the LD and control groups similar at time of 4 year followup. There were no differences between the groups regarding parents' impressions of disease impact.

CONCLUSION: In contrast to studies of adults with LD, the results of longterm followup of the pediatric population continue to strongly support the finding that children treated appropriately for LD have an excellent prognosis for normal cognitive functioning.
......................................................................................................

Although neurologic Lyme disease is known to cause cognitive dysfunction in adults, little is known about its long-term sequelae in children. Twenty children with a history of new-onset cognitive complaints after Lyme disease were compared with 20 matched healthy control subjects. Each child was assessed with measures of cognition and psychopathology. Children with Lyme disease had significantly more cognitive and psychiatric disturbances.

Cognitive deficits were still found after controlling for anxiety, depression, and fatigue. Lyme disease in children may be accompanied by long-term neuropsychiatric disturbances, resulting in psychosocial and academic impairments. Areas for further study are discussed.

Ten percent of Lyme arthritis (LA) patients have continued synovitis despiteantimicrobial therapy. The current study was designed to (1) investigatepredictors of prolonged disease and (2) further define natural history ofpediatric LA. Medical records of 94 children fulfilling Centers for DiseaseControl criteria for Lyme disease were reviewed, classified into groupsaccording to duration of synovitis, and SPSS statistical software was used foranalysis. Thirty-nine percent required >6 months and 13% required >12 months toresolve LA. Pearson correlation between duration of symptoms of LA pretreatmentand duration of synovitis was not significant. When patients were stratified bygroup, no differences were found for age, antinuclear antibodies positivity,enzyme-linked immunosorbent assay titer, or reactivity of Western blot usingparametric and nonparametric tests. Linear and logistic regression showed nopredictors of disease duration. One third of pediatric LA patients require >6months to resolve synovitis. Duration is not associated with delay in treatment,age, or seroreactivity.

Laboratory data in children with Lyme neuroborreliosis, relation to clinical presentation and duration of symptoms.

Tveitnes D, Oymar K, Natas O. From the Departments of Paediatrics. The occurrence of IgM and IgG antibodies against Borrelia burgdoferi in serumand cerebrospinal fluid (CSF) and intrathecal synthesis of antibodies (antibodyindex) were studied in relation to clinical presentation and the duration of symptoms before diagnosis in 146 children diagnosed with neuroborreliosis.Lymphocytic meningitis was demonstrated in 141 of these children. Levels of white blood cells (WBC) and protein in CSF correlated significantly to numbersof d with symptoms.

Levels of WBC and protein in CSF as well as the proportion ofchildren with antibodies in serum and CSF were generally lowest in group A,intermediate in group B and highest in group C. The proportion of children with antibodies in serum and CSF and a positive antibody index was also related to duration of symptoms; the antibody index was present in 51% of children withsymptoms </= 7 d, and in 80% of children with symptoms > 7 d (p<0.01).

The clinical presentation and duration of symptoms must be considered when interpreting laboratory data in children with suspected neuroborreliosis. PMID: 19253089 [PubMed - as supplied by publisher]

Lyme disease is a polymorphic and multisystemic disease caused by Borrelia burgdorferi. Neurological manifestations are found in 10%-50% of cases. We present 2 cases followed for 5 and 6 years of chronic relapsing-remitting neuroborreliosis. Diagnosis of neuroborreliosis in these cases was based on serum and cerebrospinal fluid findings. We discuss clinical, neurophysiological, laboratory and instrumental aspects regarding the difficulties of reaching a correct diagnosis. Further studies, especially in the field of immunology, should help identify the mechanisms responsible for the disease becoming chronic. With this knowledge, it may be possible to design immunological therapies for relapses, and to prevent the evolution of the disease.
PMID: 10933439 [PubMed - indexed for MEDLINE]

OBJECTIVE. Lyme meningitis is difficult to differentiate from other causes of aseptic meningitis in Lyme disease?endemic regions. Parenteral antibiotics are indicated for Lyme meningitis but not viral causes of aseptic meningitis. A clinical prediction model was developed to distinguish Lyme meningitis from other causes of aseptic meningitis. Our objective was to prospectively validate this model.
METHODS. Children between 2 and 18 years of age presenting to Hasbro Children's Hospital from April through October of 2006 and 2007 were enrolled if a lumbar puncture for meningitis showed a cerebrospinal fluid white blood cell count of >8 cells per µL. Cerebrospinal fluid was sent for Lyme antibody testing. The probability of Lyme meningitis was calculated by using the percentage of cerebrospinal fluid mononuclear cells, duration of headache, and presence of cranial neuropathy by using the prediction model. Definite Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with (1) positive Lyme serology confirmed by immunoblot or (2) erythema migrans rash. Possible Lyme meningitis cases were defined as cerebrospinal fluid pleocytosis with positive cerebrospinal fluid Lyme antibody. Sensitivity, specificity, and likelihood ratios for definite and possible Lyme meningitis were determined by using 10% increments of calculated probability of Lyme meningitis.

RESULTS. Fifty children were enrolled, including 14 children with definite Lyme meningitis, 6 with possible Lyme meningitis, and 30 with aseptic meningitis. A calculated probability of <10% for Lyme meningitis had a negative likelihood ratio of 0.006 for definite and possible Lyme meningitis cases. A calculated probability of >50% for Lyme meningitis had a positive likelihood ratio of 100 using these definitions.

CONCLUSIONS. A clinical prediction model using the percentage of cerebrospinal fluid mononuclear cells, headache duration, and presence of cranial neuropathy can differentiate children with Lyme meningitis from children with aseptic meningitis. Our findings suggest categories of low (<10%), indeterminate (10%?50%), and high (>50%) probability of Lyme meningitis.

OBJECTIVES. We sought to identify predictive factors for Lyme carditis in children and to characterize the clinical course of these patients.

METHODS. We reviewed all cases of early disseminated Lyme disease presenting to our institution from January 1994 through July 2008, and summarized the presentation and course of those patients with carditis. A case-control study was used to identify predictive factors for carditis. Controls were patients with early disseminated Lyme disease without carditis.

RESULTS. Of 207 children with early disseminated Lyme disease, 33 (16%) had carditis, 14 (42%) of whom had advanced heart block, including 9 (27%) with complete heart block. The median time to recovery of sinus rhythm in these 14 patients was 3 days (range: 1?7 days), and none required a permanent pacemaker. Four (12%) of 33 patients with carditis had depressed ventricular systolic function, 3 (9%) of whom required mechanical ventilation, temporary pacing, and inotropic support. Complete resolution of rhythm disturbances and myocardial dysfunction occurred in 24 (89%) of 27 patients for whom follow-up data were available. Most patients with carditis also had other systemic Lyme involvement. By using multivariate logistic regression analysis, we found that children >10 years of age, those with arthralgias, and those with cardiopulmonary symptoms were more likely to have carditis.

CONCLUSIONS. The spectrum of presentation for children with Lyme carditis is broad, ranging from asymptomatic, first-degree heart block to fulminant myocarditis. Variable degrees of heart block are the most common manifestation and occasionally require temporary pacing. Transient myocardial dysfunction, although less common, can be life-threatening. Advanced heart block resolves within 1 week in most cases. In children with early disseminated Lyme disease, older age, arthralgias, and cardiopulmonary symptoms independently predict the presence of carditis.

The underdiagnosis of neuropsychiatric Lyme disease in children and adults.

Fallon BA, Kochevar JM, Gaito A, Nields JA.

Department of Psychiatry, Columbia University Medical Center, New York, New York, USA.

Lyme Disease has been called "The New Great Imitator," a replacement for that old "great imitator" neurosyphilis. This article reviews the numerous psychiatric and neurologic presentations found in adults and children. It then reviews the features of Lyme Disease, which makes it almost uniquely hard to diagnose, including the complexity and unreliability of serologic tests. Clinical examples follow that illustrate those presentations of this disease that mimic attention deficit hyperactivity disorder (ADHD), depression, and multiple sclerosis.

Lyme borreliosis is a tick-borne spirochetal infection which affects the skin,joints, heart and nervous system. Children with a neuroborreliosis usuallypresent with a facial nerve palsy or aseptic meningitis, but the spectrum also includes other rare manifestations. We report four unusual cases of childhood neuroborreliosis and show that seizures with regional leptomeningealenhancement, acute transverse myelitis, meningoradiculitis with pain andparaesthesia and cranial nerve palsies other than facial nerve palsy can be the leading symptoms of children with neuroborreliosis.

All children had serologicalevidence of an acute infection with Borrelia burgdorferi, a pleocytosis in the cerebrospinal fluid and a complete response to antibiotic treatment. An intrathecal synthesis of IgG antibodies was detected in three children.

Thus,diagnostic work up in children with unusual neurological symptoms should include cerebrospinal fluid studies with determination of the white blood cell count andc alculation of the antibody index against B. burgdorferi.
http://eutils.ncbi.nlm.nih.gov/entrez/e ... rlinksPMID: 19748808 [PubMed - as supplied by publisher]

Acropapular dermatitis of childhood is a symmetric self-limited papulovesicular exanthem that classically occurs on the cheeks, extensor extremities, and buttocks in young children. The eruption of acropapular dermatitis of childhoodrepresents a reaction to a variety of infections usually of viral origin. We present a child with typical findings of acropapular dermatitis of childhood whose serologic workup revealed an acute Lyme infection.

Involvement of CNS. According to Dr. Pietrucha, children with neurologic Lyme disease may present acutely with headache, blurry vision, double vision, confusion, irritability, fever, and/or stiff neck. Chronically, they may be encephalopathic and have lingering headache, personality change, and depression. Patients who present acutely may have an aseptic meningitis with pleocytosis and elevated protein in the spinal fluid. Occasionally, there may be lesions on the MRI, and about 20% of patients may have abnormal EEGs.

Increased intracranial pressure with an opening pressure above 200 mm/H2O is seen much more often in children with Lyme disease than in adults. This is sometimes referred to as "pseudotumor cerebri," although it is not a classic pseudotumor picture as the children do not necessarily have to be overweight or have a problem with their menstrual cycle. The CSF pleocytosis usually improves. Frequently, it may improve even without treatment, but certainly, if the patient is treated with antibiotics, this will clear. The increased intracranial pressure responses to medications such as Diamox and seizures should be treated with anticonvulsant medications. The lesions on the MRI may remain or may disappear with time.

The most common lingering problem that patients have as a result of involvement of the CNS in Lyme is encephalopathy, which the children call "brain fog." These children complain of persistent headache and fatigue. There may be personality change, irritability, and frequently depression.

The impact academically is most significant. These children have fall-off in academic performance, difficulty learning new material, problems with short-term memory, problems with word finding, and a number of them have lost reading skills. Frequently, these children may present with a picture of ADD or may have an underlying ADD or ADHD that is made worse by the Lyme. Incidentally, Dr. Pietrucha noted that children with Tourette's may also have a worsening of their tics when they have been ill with Lyme disease symptoms. A case report published in Lancet indicated that a child with Tourette's who was found to have concurrent CNS Lyme disease experienced a remission of the Tourette's after the Lyme disease was treated.

This Lyme encephalopathy merits special attentions because it has a significant impact educationally and also economically. These children may require at-home tutoring, necessitating a parent to stay home from work to be with the child. When they return to school, many frequently need a shortened schoolday and continued home instruction. Many have to be classified as "other health impaired" and receive ongoing services, such as Resource Room. A number of these children need to be placed on medication for their short attention spans and distractibility, as any other ADD patient would require. Frequently, the depression has to be treated, both with medications and counseling.

In addition to the impact on these children educationally, there is a social burden because they cannot participate in extracurricular activities and they lose contact with peers.
Peripheral nervous system. Patients may present with a sudden onset of weakness. It may be facial weakness, weakness of an extremity, or an ascending weakness or paralysis. There may be pain, a burning sensation in the extremities, numbness, tingling, and myalgia.

Children do not have involvement of the peripheral nervous system as frequently as they have involvement of the CNS. The most common peripheral nervous manifestation in children is Bell's palsy, with a sudden onset of facial palsy. Rarely, there has been involvement of an isolated extremity or even an isolated nerve involvement, such as the peroneal nerve. Patients have presented with a picture very typical of Guillain Barré (GB), and many children do complain of a burning sensation, numbness, and tingling -- although this is a mild sensory neuropathy. There have been cases of children presenting with muscle pain, weakness, and elevated CPK.

In addition to treating their Lyme disease with appropriate antibiotic therapy, these patients may require physical therapy, anti-inflammatory medication, and analgesia. Patients presenting with a picture that is typical of GB should be treated like a GB patient, keeping in mind that if the underlying cause is Lyme disease, then that too must be treated. Overall, the prognosis for children to show a complete recovery from involvement of the peripheral nervous system in Lyme disease is very good, probably better than in the adult population. Bilateral Bell's palsy has certainly been seen in Lyme disease in children. The incidence of bilateral Bell's palsy in Lyme is greater than the incidence of bilateral Bell's palsy from other causes.

Conclusion. Dr. Pietrucha's talk was based on years of clinical experience treating hundreds of children with mild-severe neurologic Lyme disease. In the question-and-answer session, she described one child with refractory generalized seizures not responsive to anticonvulsants who was also experiencing joint pain. This child tested positive for Lyme disease and responded with a remission of the seizures. The treatment course was prolonged and led to an overall dramatic improvement in clinical symptoms. Dr. Pietrucha also noted that complex partial seizures have been described in the medical literature among children with chronic Lyme disease.
Psychological Evaluation of Pediatric, Neurologic Lyme Disease Background. Children with Lyme disease may experience cognitive difficulties that interfere with school performance. Studies have demonstrated deficits in the areas of attention, memory, language and reasoning in adult subjects.[1-4] Other studies have explored the nature and extent of cognitive or academic dysfunction in children with Lyme disease,[5-8] though little attention has been directed toward the development of educational programs to deal with the issue. Marian Rissenberg, PhD, of Columbia Presbyterian College of Physicans & Surgeons, New York, presented a talk on the neuropsychological evaluation of children with Lyme disease. Dana Leonardi, MA, has been an integral part of this research.

Methods. In this pilot study, Dr. Rissenberg evaluated 8 children aged 7 to 13 years (mean, 9.1) with physical, cognitive, and emotional symptoms related to Lyme disease who had neuropsychological evaluation, including academic testing early and again later in the course of their antibiotic treatment. Physical symptoms reported at the initial evaluation (E1) included fatigue, joint pain headaches and irritability. Also reported were difficulties with schoolwork, concentration, and memory; sleep disturbance; sensory sensitivity; mood swings; impulsivity; depressed mood; anxiety; motor tics; word retrieval difficulty; balance problems; and temper outbursts.

Results. Dr. Rissenberg's results indicated that at the time of E1, even after completing from 1 to 5 months of high-dose antibiotic treatment, children had significant cognitive deficits. As a group, the subjects had a significant discrepancy between Verbal and Performance IQ, and a significantly deficient Performance IQ. There was a significant degree of inter-subtest variability on the WISC-III, with scores ranging from the 20th to 93rd percentile. Scores were lowest on tests sensitive to speed of processing, visual scanning, sequencing, and causal reasoning. Deficits were noted on 2 attention tasks, one sensitive to visual scanning and sustained attention and the other to auditory tracking. While there were no statistically significant memory deficits evident at E1, the data suggest that delayed recall of both verbal and visual material is deficient. On tests of language function, performance was deficient on a task requiring production of sentences containing a given word. On academic measures, half the S's were behind grade expectation in 2 measures of reading comprehension, as well as spelling. Most S's were above grade expectation in Basic Reading, Mathematics Reasoning and Numerical Operations. Reading skills were more advanced than math skills.

At E2, following 10 to 32 months (mean, 17) of additional antibiotic therapy, all subjects reported significant improvement of physical and emotional symptoms, with only 1 having continued headaches and another having sleep disturbance. Five experienced improvement in cognitive and academic difficulties, though 4 continued to have some cognitive complaints and 5 continued to have some emotional issues. Two continued to have both cognitive and emotional symptoms, and 1 had both physical and emotional symptoms.

Results from repeat administration of the WISC-III at E2 revealed significant improvement in Verbal and Performance IQ, with less of a spread between the two. Full Scale IQ and the Perceptual Organization Index also showed significant improvement. Marked improvement in performance was shown on those subtests that were deficient at E1, specifically Picture Arrangement, Comprehension, Object Assembly, and Coding, as well as Arithmetic. This strongly supports the notion that these deficits were secondary to Lyme disease and that their improvement is attributable to antibiotic treatment. Visual scanning and sustained attention improved, while auditory tracking showed less improvement. Performance on sentence production improved. Significant improvement was noted on the Verbal Immediate Memory Index and the General Memory Index of the CMS. Short-term memory impairment is no longer apparent. Gains were made in academic achievement in all areas, with the exception of Numerical Operations (paper and pencil calculations). However, even with 6 S's dropping an average of 1 year and 3 months, only 2 fell below their expected GE. Gains were demonstrated on 3 separate measures of reading comprehension and on reading speed and accuracy. Scores on tests of mathematical calculations and fund of general and word knowledge declined. This is interpreted as reflecting a decreased rate of learning and a widening of the gap between children with Lyme disease and their healthy peers over the course of the study.

Implications. Dr. Rissenberg noted that the results provide preliminary support for broadening the CDC diagnostic criteria, extending antibiotic treatment in children, and conducting careful neuropsychological evaluation and educational monitoring. Development of educational programs for the identification, accommodation, and remediation of Lyme disease-related academic difficulties is critical as the numbers of children with the disease increases. Lyme disease-related cognitive deficits represent acquired, as opposed to developmental, learning disabilities and attentional disorders. Educational services and modifications should include, when necessary, reduction of homework, extended time for tests, provision of classroom notes and course outlines, instruction in organizational, time management, and study skills strategies, availability of abridged or tape-recorded books, shortened schoolday, and home instruction. Support may be necessary even after treatment for Lyme disease has been completed. Education of teachers and other school personnel regarding the educational impact of Lyme disease, as well as resources for parents, must be available. Dr. Rissenberg noted that further study is needed, using larger groups and more stringent controls, of the cognitive and academic functioning, physical and psychiatric symptomatology, and treatment response in children with Lyme disease.

Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus
Medical Center Rotterdam, The Netherlands.

Objective:We report a typical case of earlobe lymphocytoma.
Method:A case report and literature review are presented.
Results:A 10-year-old girl presented with a blue-coloured earlobe. A
diagnosis of Lyme disease was confirmed by serological tests. Lyme
borreliosis is the most common tick-borne disease in the northern
hemisphere. It is caused by the spirochete Borrelia burgdorferi sensu
lato. The patient was successfully treated with antibiotics.
Conclusion:The diagnostic process and ENT symptomatology of Lyme disease
and borrelial lymphocytoma are summarised and discussed.

Lyme Disease, caused by the spirochete Borrellia burgdorferi, is the most common vector-borne disease in the United States. Clinically, it primarily affects the skin, joints, nervous system, and heart. Lyme carditis occurs in 4%-10% of adults with Lyme disease. Transient variable-level atrioventricular blocks, occurring in 77% of adults with Lyme carditis, are the most common cardiac manifestation. Up to 50% of Lyme carditis patients may develop complete heart block. The incidence of Lyme carditis in the pediatric population is not well established. We present a pediatric patient with a transient asymptomatic complete heart block resulting from Lyme carditis, an under-recognized complication of Lyme disease in the pediatric population.

?Lyme disease is aptly called the ?new great imitator,? and it can imitate psychiatric disorders no less than medical ones. Psychiatrists working in endemic areas are well advised, then, to keep Lyme disease in mind as part of their differential diagnosis for a broad range of disorders including, for instance, panic attacks, somatization disorder, depression, and dementia.?

We studied retrospectively the medical records of all patients diagnosed with neuroborreliosis (NB) by cerebrospinal fluid (CSF) analysis in Jönköping County, Sweden, during 2000-2005 (n=150). The number of NB cases increased from 5 to 10/100,000 inhabitants/year. In 17% of the patients, Borrelia-antibodies were found in CSF but not in serum at the time of diagnosis. Facial palsy, headache and fever were frequent manifestations in children, whereas unspecific muscle and joint pain were the most commonly reported symptoms in older patients. Symptoms persisting more than six months post-treatment occurred in 13%, and these patients were significantly older, had longer duration of symptoms prior to treatment, higher levels of Borrelia-specific IgG in CSF and more often radiculitis. The total cost for NB-related health care was estimated to 500,000 EUR for the entire study group (3,300 EUR/patient), and the cost for social benefits to 134,000 EUR (2,000 EUR/patient). CSF analysis is necessary for NB diagnosis since some patients develop antibodies in serum later than in CSF. Early diagnosis of borreliosis would result in reduced human suffering and economic gain.

Objective
Systemic bacterial and fungal infections may sometimes present local
manifestations within otolaryngological district whose early detection
may be useful in establishing a correct diagnosis and more appropriate
treatment. This paper reviews certain systemic bacterial and fungal
diseases presenting ENT manifestations in the pediatric population from
an otolaryngological perspective.

Methods
A medline searching for specific issues was performed in order to
achieve more information as possible with regards to ENT manifestation
of systemic bacterial and fungal infections. Limits for pediatric age
were used. Two separate sections for bacterial and fungal disease are
included. The section on systemic bacterial infections considers
cat-scratch disease, Lyme borreliosis, actinomycosis, Lemierre's
syndrome and congenital syphilis, and the section on systemic fungal
infections includes candidiasis, aspergillosis and histoplasmosis.

Conclusions
Pediatricians and ear, nose and throat (ENT) specialists, approaching
head and neck disorders in children, should therefore consider them
among the possible differential diagnoses. This means that physicians
need to recognize the first head and neck manifestations of systemic
infections promptly in order to be able to treat them efficaciously and
avoid the dangerous systemic spreading of the infective process.

Lyme neuroborreliosis (LNB) represents the second most frequent manifestation of
Lyme disease (LD) in Europe after cutaneous involvement. In the USA, LNB
represents the third most frequent manifestation of LD after cutaneous
involvement and arthritis. The scope of this article is, in the light of recent
publications, to review the specific manifestations of LNB in children including
predictive models, and to discuss diagnosis criteria, new diagnostic tools and
new therapeutic options. Differences in disease patterns between the USA and
Europe are also highlighted.

Lyme neuroborreliosis (LNB) represents the second most frequent manifestation of
Lyme disease (LD) in Europe after cutaneous involvement. In the USA, LNB
represents the third most frequent manifestation of LD after cutaneous
involvement and arthritis. The scope of this article is, in the light of recent
publications, to review the specific manifestations of LNB in children including
predictive models, and to discuss diagnosis criteria, new diagnostic tools and
new therapeutic options. Differences in disease patterns between the USA and
Europe are also highlighted.

OBJECTIVE: Children often develop arthritis secondary to Lyme disease; however,
optimal treatment of Lyme arthritis in pediatric patients remains ill-defined.
We sought to characterize the outcomes of a large cohort of children with Lyme
arthritis treated using the approach recommended by the American Academy of
Pediatrics and the Infectious Diseases Society of America.

METHODS: Medical
records of patients with Lyme arthritis seen by rheumatologists at a tertiary
care children's hospital from 1997 to 2007 were reviewed. Patients were
classified with antibiotic responsive or refractory arthritis based on absence
or presence of persisting joint involvement 3 months after antibiotic
initiation. Treatment regimens and outcomes in patients with refractory
arthritis were analyzed.

RESULTS: Of 99 children with Lyme arthritis, 76 had
arthritis that responded fully to antibiotics, while 23 developed refractory
arthritis. Most patients with refractory arthritis were successfully treated
with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid
injections (4), or disease-modifying antirheumatic drugs (DMARD) (2). Five were
lost to followup. Six patients with refractory arthritis were initially treated
elsewhere and received additional antibiotic therapy, with no apparent benefit.
Three subsequently required DMARD, while 3 had gradual resolution of arthritis
without further therapy. Antibiotic responsiveness could not be predicted from
our clinical or laboratory data.

CONCLUSION: Lyme arthritis in children has an
excellent prognosis. More than 75% of referred cases resolved with antibiotic
therapy. Of patients with antibiotic refractory arthritis, none in whom followup data
were available developed chronic arthritis, joint deformities, or recurrence of
infection, supporting current treatment guidelines.

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I'm a practicing physician in New York State. Most of my career has been in emergency psychiatry. I love medicine. My favorite thing about my work is diagnosing medical illness that my non-psychiatric colleagues have missed.

My two favorite such anecdotes: being called to admit to psych a 54-year-old woman with no prior psychiatric history and presenting with psychosis. Knowing that most "functional" psychotic illnesses first manifest early in life, I consider the likelihood that there is an underlying disease process causing this psychosis. The emergency physician walks me to the patient's cubicle, pulls aside the curtain, and before he can say another word, I remark, "Did you know notice the classic lupus malar rash?" She looks like someone painted rough patches of red paint across her cheeks. We run the tests, and sure enough, her ANA comes back supporting the diagnosis of LPE and she is admitted to medicine for treatment of lupus cerebritis. He didn't even see the rash because she was a "psych patient."

Another:

I get called to see a Jane Doe. A 34 year old disheveled, malodorous woman who was found in a public park, naked in a fountain, urinating into her hands and drinking the urine. (You can't make this stuff up!) Since she raving and not making any sense, I get called to admit her to psych. I read the chart and notice the nurses have documented that she has vomited once. I also notice, that despite her agitation, her heart rate is only 74----I'd expect it to be higher. I suggest a brain MRI, thinking increased intracranial pressure. They medicate her, scan her, and find the subdural hematoma.

I write this, not with pride, but with shame, because I missed my own son's diagnosis of TBD.

My beautiful son, Greg is twenty years old. At 3 he was diagnosed with high-functioning autism. At 8 he developed anxiety symptoms and at 10 he was treated for depression and anxiety with Zoloft by a child and adolescent psychiatrist. At 14, he developed episodic periods of agitation and depression, and because of a history of bipolar II disorder in his father's family, was treated with Tegretol, Lamictal, Klonopin, lithium, and Seroquel in addition to the Zoloft.

Despite all these medications, over the past 3 years, my son has deteriorated significantly. He has had increasing confusion, difficulty concentrating, panic attacks, episodic agitation, depression, fatigue, loss of ability to drive, getting lost walking in our familiar neighborhood. His balance is off, and he falls down a lot. He has had to stop driving and dropped out of college, where he had been a 3.8 GPA student.

A few months ago, I remember thinking, "Something is taking my child away from me", as in the sense of something organic eating away at his personality. I thought he might be toxic on his medications, but his blood levels were always therapeutic. I thought his unrelenting psychiatric symptoms were just eroding his brain, like some very ill schizophrenic patients can look after years of illness.

A few weeks ago a friend of mine was diagnosed with Lyme Disease. She told me,, "I'm so confused. I got lost driving to the market." And it triggered something in me because I've heard my son say those things. He was due for his routine labs----chem profile, drug levels, etc.----and I asked his treating psychiatrist to "throw in a Lyme test", without even knowing what "testing for Lyme" might mean.

His ELISA came back positive. His Western Blot came positive with bands at 18, 23, 30, 39. 41, 58, and 93:all IgG.

There is no telling when he got this infection. He's found solace in the woods since he was a little boy. We live on property without fences, have a vegetable garden, and see deer tracks in the snow across our yard every year. Who knows?

I have spent the last couple of weeks filling in the huge empty spaces in my knowledge base about TBD, reading everything I can get my hands on.

The mother part of me is horrified, absolutely horrified. The citizen part of me wants to march on Washington. And the physician part of me is fascinated.

I remember one patient from when I was an intern. She came into the hospital with an acute uveitis and acute renal failure, and no established diagnosis. I had to do her initial admission history and physical. I did as I was taught, starting with the question, "when was the last time you were well?" Taking a careful detailed history of her symptoms, not assuming anything, including asking about travel, exposure to toxins, infections, etc. It took me nearly two hours to complete her admission H&P, and another hour to write it up. The ophthalmologists and nephrologists who came to see her also didn't know what syndrome she had. Their fellows did literature searches, and included the one or two articles in her chart. I found this process fascinating, because we didn't know.

That's the part of me that is fascinated by TBD medicine. Because of what we don't know.

Well, I clearly don't know, and just as clearly others do-----and I hope to learn from you. God willing, when I get my son well and he's back on course, I hope to learn a lot more and put it into practice treating others stricken with this horrible illness.

Pediatrician seeks to raise awareness of prevalence of Lyme disease among youth

By CATHLEEN F. CROWLEY Staff writer

Updated 09:24 a.m., Thursday, May 12, 2011

Last summer, 3-year-old Colin McMahon started acting strange. He couldn't focus, he swiped his hands over his face nonstop, and he became anxious -- to the point where he wouldn't go into a room by himself.

Colin's parents finally figured out what was wrong: The boy had Lyme disease.

Lyme is the most common of all the diseases in the United States transmitted by mosquitoes, ticks and fleas, with approximately 20,000 cases reported each year nationally. New York has the second-highest rate of Lyme in the United States, with nearly 6,000 cases reported in 2009. Public health officials say the number of undiagnosed cases is probably higher than that.

Most illness occurs in June, July and August, when the infected ticks are most active. Bartholomew Forlano, a veterinarian at the Glenville Veterinary Clinic, said this year's cool, wet spring is the perfect climate for ticks, and he is seeing many of the critters in his practice.

The incidence of Lyme among humans is highest in two age groups: adults between 55 and 69 and children between 5 and 14, particularly boys.

"He was so young, and I thought he was going through a phase," said Darlene McMahon, Colin's mother, who lives near Plattsburgh.

Lyme symptoms come in many forms and are hard to pin down in children, said Dr. Kari Bovenzi, an Albany pediatrician who treats many kids with the ailment.

Children have trouble explaining their symptoms and don't have a reference point for what is normal, Bovenzi said. The tick itself is rarely seen and the bull's-eye rash associated with Lyme only appears in 7 percent of cases, she said. On top of that, tests for Lyme are unreliable.

"It's tricky to prove what is going on," Bovenzi said.

Lyme can attack any organ in the body, including the brain, leading to a befuddling spectrum of symptoms in children that might include poor concentration, short-term memory problems, irritability, fatigue, fever, body pain, speech problems, facial paralysis and seizures.

Consequently, Lyme has been misdiagnosed as attention deficit disorder, behavioral problems and even autism, Bovenzi said.

The pediatrician has organized lectures aimed at training physicians about Lyme, but only a handful of doctors showed up.

She said pediatricians need to be educated about the disease, especially in New York where Lyme is widespread. And if they have a patient with inexplicable symptoms, "You better think about Lyme."

Doctors told Allison Accettella that she was depressed, and that her aches and pains were in her head.

But the Saratoga Springs teenager knew something was wrong physically. Last summer, she started sleeping 14 to 16 hours a day, she had reoccurring fevers, and her joints hurt so much she could barely walk. Allison gave up lacrosse, a sport she loved, and had to be tutored at home because she physically couldn't make it to Saratoga Springs High School.

In September, Allison woke up with an excruciating pain in her face. The left side of her face was paralyzed, a sign of Bell's palsy and a trademark of Lyme disease. Blood tests confirmed that she had Lyme, and Allison was put on three weeks of antibiotics, the mainstream treatment for the illness. It didn't help.

There is a split in the medical community over Lyme disease. The Infectious Disease Society of America recommends treating suspected Lyme cases with a short course of antibiotics and, if the symptoms persist, with another four weeks of antibiotics. The International Lyme and Associated Diseases Society recommends longer courses of antibiotics that end when the patient feels better.

Allison went to several infectious disease experts across the state. They told her she needed a psychological evaluation. One instructed her "to eat more vegetables and stop sleeping so much."

It broke her heart.

"It was so upsetting that nobody believed me," she said.

Then Allison found Dr. Bovenzi, who put her back on antibiotics. Allison is walking again and attends school as much as she can in addition to receiving home tutoring.

Colin is also on antibiotics and 90 percent of his symptoms are gone, his mother said. McMahon has started a national group to connect families of children infected by Lyme and educate people about the variety of symptoms that accompany the disease. The group is called the Children's Lyme Disease Network and can be reached at info@childrenslymenetwork.org.

From the *Department of Orthopaedics and Rehabilitation, daggerDivesion of Pediatric Orthopaedics, double daggerPediatric Rheumatology and Rheumatology, Milton S. Hershey Medical Center, The Pennsylvania State University College of Medicine, Hershey, PA.

Lyme disease is the most common tick-borne disease in North America. Our review of the literature found few reports of Lyme disease presented in the orthopaedic literature. However, Lyme disease presenting as a popliteal cyst, with or without rupture, is rarely reported. We present 4 cases of Lyme disease that initially presented to our pediatric orthopaedic clinic for treatment of a popliteal cyst. The early diagnosis and treatment of Lyme disease may help prevent the often-devastating long-term sequelae of Lyme disease. The goal of this article is to increase the awareness of Lyme disease presenting in children as a popliteal cyst.

Tick-borne encephalitis (TBE) and neuroborreliosis (NB) are well-known central nervous system (CNS) infections in children. Childhood tick-borne CNS infections are generally described as mild conditions. However, this view has recently been challenged, and the natural course, including potential sequelae, has been debated. If the diseases present with nonspecific symptoms and signs, some children may elude diagnosis.

This study estimates the incidence of symptomatic tick-borne CNS infections in children under medical care and describes the spectrum of manifestations.
One hundred twenty-four children with neurologic symptoms attending the Pediatric Emergency Department were included prospectively. Anti-TBE virus and anti-Borrelia serology results were analyzed together with inflammatory parameters in the blood and cerebrospinal fluid.
Nearly one fourth of the children with neurologic symptoms were diagnosed with a tick-borne CNS infection (TBE, n = 10 [8%] and NB, n 21 [16.8%]). In general, these children displayed an indistinct medical history and presented with nonspecific signs such as malaise/fatigue and headache. Diagnosis was based on analysis of acute and convalescent sera. Blood inflammatory parameters were nonspecific and did not contribute to the diagnostics.

Conclusion: Pediatric tick-borne CNS infections are unexpectedly common and should be considered in children with unspecific and unexplained acute CNS-related symptoms.

Lyme arthritis most commonly affects the knee. It is not commonly considered in the differential diagnosis of monoarticular hip pain. There are only a few case reports describing Lyme disease presenting with isolated hip involvement. The purpose of this study is to review our experience with primary Lyme arthritis of the hip.

December 2013- Over twice as many children had Lyme related arthritis affecting the knee than both septic arthritis and "other" causes of arthritis combined. And that was based on having to have a positive Lyme test!

"We identified 384 children with knee monoarthritis, of whom 19 (5%) had septic arthritis, 257 (67%) had Lyme arthritis and 108 (28%) had other inflammatory arthritis."

BACKGROUND:Although Lyme and septic arthritis of the knee may have similar clinical presentations, septic arthritis requires prompt identification and treatment to avoid joint destruction. We sought to determine whether synovial fluid cell counts alone can discriminate between Lyme, septic, and other inflammatory arthritis.

METHODS:We conducted a retrospective cohort study of children aged 1 to 18 years with knee monoarthritis who presented to 1 of 2 pediatric emergency departments located in Lyme endemic areas. We included children who had both a synovial fluid culture and an evaluation for Lyme disease.